02/22/2014

Clinical Symptom Integration Notes

8/12/13 - Chest Pain
9

month old child w/ cc of chest pain

Vaginal delivery, no complications
Vaccinations up to date
Exam
o No distress, normal color, runny nose, tachypnea, mild
wheezing, decreased air entry in the lungs
Differential Diagnosis
o URI, flu, trauma, septal defect, bronchitis, asthma, cystic
fibrosis, Wolf Parkinson white syndrome, trauma, foreign
body, GERD, acid reflux, pneumonia, pneumothorax,
congenital heart defects, tumor, cancer, pertussis, pleuritis,
pericarditis, esophagitis, hiatal hernia, lung abcess,
dermatitis, inhaled or exhaled rib, borhoff syndrome,
hepatitis, pancreatitis, gastritis, endocarditis, dissected aorta,
colic
23 year old man with cc of chest pain
In tears, no significant medical history, vital signs are stable,
physical exam unremarkable, some tenderness in costosternal area
Differential diagnosis
o Appendicitis, rib fracture, heart problems, illicit drug use,
pneumoepigastrium, GSW, acid reflux/heart burn, carcinoma,
bacterial infection, pericarditis, muscle strain, medication
side-effect, anxiety attack, GERD, hiatal hernia,
costochondritis, sickle-cell anemia, PE, drug-seeker, bulimia,
gall bladder disease, appendicitis, peptic ulcer, aortic
dissection, pneumothorax, tuberculosis, MI, coronary
vasospasms, marfan syndrome, costochondritis, tumor,
cancer, arrhythmia, cardiomyopathy, electrolyte abnormalities
32 year old female with cc of chest pain and SOB
Had a child 2 weeks ago (normal vaginal delivery), 200 lbs, no
diabetes, no HTN
Coaurse breath sounds bilateral, decreased breath sounds
bilaterally, tachycardic

Differential diagnosis
o PE, diaphragmatic defect due to birth, pleuritis, empyema,
pneumonia, CHF, atelectasis, cardiogenic shock, infection
secondary to skin lesion, cardiac tamponade, lupus, shingles,
MI, acute coronary syndrome, angina, muscle strain,
rheumatoid arthritis, valvular diseases, rheumatic vlavular
disease, endocarditis, GERD, coronary artery disease

65 year old woman with severe chest pain (sharp, in tears and severe
distress)
Hx of diabetes, HTN, previous MI, CHF, smoking, alcohol, edema in
legs
Tachycardic, tachypnic
Lungs clear, chest clear
Differential Diagnosis
o MI, pulmonary embolism, COPD, coronary artery disease,
Risk factors
o Genetic and non-genetic, preventable and non-preventable,
COPD, pulmonary HTN, aortic aneurysm, drug interaction,
neuropathy, bronchitis, pneumonia, esophageal spasm,
esophageal diverticulitis, tumor, ulcer, asthma,

08/13/13 Introduction to neurology and approach to the neurologic

complaint
Case #1: John
34 years old
CC: headache
HPI: old carts
o Had headache 1x prior, started last night, around the whole
head (headband distribution), no trauma, constant, tylenol
helped, laying down helps, associated nausea, 5/10, no
radiation, no temporal patterns, loud noises make it worse, no
tearing or runny nose

PMH
o Anxiety, no medications or supplements, drinks monster (2-4
per day; had caffeine yesterday),
Differential diagnosis: vasodilated cerebral arteries migraine
(doesnt have to be unilateral), HTN, tumor, aneurysm (ruptured),
stroke (hemorrhagic - subarachnoid), concussion and postconcussion syndrome, tension or cluster headache, dehydration
(d/t caffeine), electrolyte imbalance, hypoglycemia
Always ask first headache, worst headache, or atypical

Case #2: Mary

CC: Dizzy
HPI: onset of 2 hours ago, room is spinning, 67 years old, constant
dizziness, staying still makes it better, no weakness or numbness,
has happened 2 times before (6 months and 2 years), gets worse
with movement
Differential diagnosis: hypotension, dehydration, vestibular
dysfunction/vertigo, meningitis (stiff neck, fever, headache), otitis
media (would be atypical)
CT to look for posterior bleed (due to abnormal finger-nose test and
high BP)
You must be careful with dropping BP rapidly, because if its an
ischemic stroke, lowering BP will result in growing of penumbra d/t
inability of blood to diffuse to distant sites through secondary and
tertiary vessels
With true nuchal rigidity, the head, neck and upper back move in
unison/as a single unit
Case #3: Rudolph
CC: Weakness
HPI: what kind of weakness (generalized or focal; if generalized it is
probably not in the brain)
Differential diagnosis: food poisoning, stroke, traumatic injury,
malnutrition, dehydration
Watch out for cauda equina (presents with extremity pain, not back
pain)
Case #4: Yolanda
CC: Numbness

HPI: where is it (hands and feet)

DD: peripheral nerve compression, stroke, diabetic neuropathy,
exposure to chemicals, nerve compression, tumor, anxiety, MS
o Use history/physical to determine if dizziness is a CNS or nonCNS problem
CT is better than MRI to visualize bleeding (MRI better for ischemic
stroke)
Vertical nystagmus indicates brainstem injury and horizontal
nystagmus indicates peripheral nervous injury
Other neurological complaints
o Seizures due to hypoglycemia, fever (in children febrile
seizures; due to rate of change of temperature), alcohol
withdrawal
Common neurological complaints
o Headache, numbness, weakness, pain, dizziness, vision
changes
Problems with herbal supplements
o Dosages arent standardized/regulated, theyre often tainted
with other medications, they arent FDA approved
ADEK vitamins are non-soluble, so excess levels cant be excreted
in urine
What type of things outside the brain cause neurologic symptoms
o Hypoglycemia
o Uremia
o It is unknown why these to causes lead to focal problems that
mimic strokes
Neuro exam summary
o CNs, proprioception and cerebellar function, sensory,
reflexes, muscle strength, mental status
The 1-minute neurologic exam
o Alertness and orientation
o Speech

Dysarthria is mechanical
Aphasia has to do with whether or not the words are
coming out or not
Motor function
o Extremity movement
o Ambulation
o Cranial nerves
Neuro ROS
o Dizziness/LOC, HA, language or speech problems, blurred
vision, blindness, numbness, tingling, memory problems,
seizures, weakness, heaviness, stiffness, mental
status/personality changes/disoriented, coordination problems
(writing, walking, eating, etc.)
Make sure you can justify every test you order
Most common neurologic cause for loss of consciousness is seizure
If you lose consciousness d/t a tumor, you likely arent waking up
(du to edema and pressure that is present as a result of it)
o Same with strokehemorrhagic

8/19/2013 Headache
Pt: Antonio Gomez
CC: headache
o What can a headache represent
o Tension headache, cluster headache, migraine, dehydration,
malnutrition, drug use (i.e. cocaine), caffeine withdrawal,
alcohol abuse, trauma, subarachnoid hemorrhage, meningitis,
stroke, influenza, cancer/tumor, meningitis, encephalopathy
(encephalitis), hypoglycemia, too much loud noises, carbon
monoxide poisoning, strep throat
OLD CARTS
o O: slowly while at work (eliminates subarachnoid
hemorrhage, which has fast onset)

o L: frontal portion of the head (could be cluster headache)

o D: 24 hours
o C: throbbing (migraine)
o A: light makes it worse; nothing makes it better
o R: no radiation
o T: constant since onset
o S: 8/10
Differential diagnosis
o Trauma, migraine, subarachnoid hemorrhage
PMH: HTN; no surgeries
Meds: hydrochlorothiazide (25mg daily)
Allergy: NKDA
SH: accountant; married to Maria; denies any tobacco or illicit drug
use; social etoh
Family Hx (FH): HTN and DM
ROS: visual system (visual changes), fever, vomiting, etc.
Encephalitis vs meningitis
o M: lethargy and sickly
o E: change in mental status
What is the most concerning symptom associated with headaches?
o Stiff neck*****
Indicates meningitis, encephalitis, subarachnoid
hemorrhage, somatic dysfunction

o Vomiting
Concussion, increased intracranial pressure, migraine,
influenza, aneurysm
o Photophobia
Migraine, drug reaction,
o Fever
Meningitis, influenza, subarachnoid hemhorrage, PE,
pneumonia
o Phonophobia
Migraine
Easily bruises and bleeding
o Microcytopenia, cancer, hemophilia, sepsis, anemia
Lungs CTAB clear to auscultation bilaterally
Without W/R/R wheezing, rales, ronchi
Spasms in trapezius and splenius capitis
What OMM techniques could be used
o Myofascial release
o FPR
o Strain-counterstrain
o Typically use and indirect technique with an acute episode
Treatment
o NSAIDS, control blood pressure,

Catamenial headaches
Migraines that occur before a womans menstrual cycle
What are some shortcomings of CT
If subarachnoid hemorrhage has been going on for 24+ hours, bad
for stroke detection
Papilledema
Swelling of optic disc indicative of increased intracranial pressure
Nuchal rigidity
Indicative of meningitis; cant move head independently of body
Meingismus
When nuchal rigidity, photophobia, and headache are present
without an actual infection

08/20/13 TBI
How do we define TBI
An alteration in brain function or other evidence of brain pathology
by an external force
How do we diagnose TBI

TBI is a process, not an event

Secondary injury can be more damaging than primary injury
Main mechanisms of brain injury
Brain contusion
Increased intracranial pressure papilledema
Diffuse axonal injury
Primary vs Secondary injury
Primary
o Irreversible cellular injury as a direct result of the injury
o Prevent the event
Secondary injury
o Damage to cells that are not initially injured
o Occurs hours to weeks after injury
o Prevent hypoxia and ischemia (hypotension increased
ischemia)
Mechanism 1: Brain Contusion
A brain contusion is defined by cell death accompanied by
hemorrhage (leakage of blood)
The soft brain tissue is vulnerable to contusion in head trauma
The contusion often occurs at a site distant from the point of impact
o Countercoup injury
An injury on the opposite side of initial impact of head
due to brain being thrown backwards after initial impact
against interior of calvaria (coup injury)
Mechanism 2

The volume of the intracranial vault is fixed

Intracranial contents
o 80% brain tissue
o 10% blood
o 10% CSF
An increase in the volume of any of these intracranial contents
causes increased intracranial pressure
o The brain can swell (edema)
o Excess blood can accumulate due to hemorrhage
o CSF can accumulate due to blockage of outflow
There is only one way out of the intracranial vault (the foramen
magnum
When the brain is squeezed through the foramen magnum
(herniation), the brainstem is compressed, the patient stops
breathing, and the patient dies
Mechanism 3
Diffuse axonal injury
One of the major causes of unconsciousness
Normal physiology of head
Brain consumes 20% of total O2
Receives 15% of CO
Brain tissue perfusion
o CPP vs CBF
CPP = MAP-ICP
MAP = (SBP-DBP/3) + DBP

o Autoregulation
50-150 mm Hg
intracerebral pressure
Facts and Figures
o Dont need to know statistics
o Males 15-24 TBI cost is highest in Chicago due to gang
violence and guns as well as sports
o Males over 65 TBI cost is high due to falls
Key history in head injury
Mechanism of injury (rely on family and police because pts
judgment an mental integrity is compromised)
Pts condition prior to incident (baseline)
Co-morbid factors
o HTN, arteriosclerosis could affect approach to treatment due
to risk of exacerbating disease
Pts immediate post trauma condition
o Confusion, agitation, malaise, etc.
Pts current medical condition
o Could affect treatment choice
When it comes to medicine it is always better to due a commission
than an omission
Where are the other injuries
Mechanism of injury can be a key determinant of other injuries
Always consider a spinal cord or vertebral column injury in a pt with
a TBI
o Especially in pts that are unconscious

o Remember: SCIWORA
Spinal cord injury without radiographic abnormality
o Assume a spinal cord or cervical spine injury until proven
otherwise
Always gradually change levels (glucose, electrolytes, temp, etc.)
Acute Neuro exam
Airway (while maintaining cervical spine stabilization)
Breathing
Circulation
Disability
Exposure
Prevent secondary brain injury
o Hy[oxemia, hyperglycemia, hypotension, evacuation of mass,
anemia
Airway control with cervical spine immobilization
o If a definitive airway is needed orotracheal
o Pupil assessment
o Motor gross function (posturing)
Decerebrate vs decortical
Glasgow coma scale
o Can give you a subjective, universal measure of the patients
condition
Can give you a baseline to compare progress or decline
against
Concussion

Any alteration of cerebral function caused by a force to the head

with any or one
o Brief LOC, headache, visual changes, personality change,
fatigue, balance disturbances, light headed, concentration,
disruptions, amnesia
Having a concussion makes it easier to have subsequent
concussions
Involves a degree of diffuse axonal injury and necrosis
Scalp laceration
May lead to massive blood loss
o Excessive vasculature that is pulled tight by scalp layers
Small galeal lacerations may be left alone
Skull fracture
Temporal bone is most common bone fractured (petrous portion)
(EAC and TM)
Dural tear
CSF testing
Should be started on antibiotics
Epidural hematoma
Rupture of middle meningeal artery
Associated with fracture of temporal bone
o Rapid expansion under systemic arterial pressure
o Lucid interval
Subdural hematoma
Rupture of bridging veins
Seen in elderly, alcoholics, blunt head trauma, shaken baby

o Slow development due to low pressure venous system

Can develop over days to weeks
CT shows
Subarachnoid hemorrhage
Rupture of an aneurysm
o Usually a Berry aneurysm or AVM
Can be traumatic or atraumatic
o Atraumatic: hypertension
Spider hemorrhage near circle of willis
Intraparenchymal hematoma
Typically does not rapidly expand or cause significant edema or
midline shift
o Unless pt is on an anticoagulant
o Diagnosed by CT scan
Diffuse axonal injury

o 08/20/13 Spinal Cord Injuries

o
o Always assume that the mechanism of injury was a bad one
until proven otherwise
o Cervical vertebrae are the most susceptible to injury
Less musculature
Less associated structures

Supports head lack of balance

C7-T1 is most susceptible
o Complete injury
The complete absence of sensory and motor function below the
level of injury
o This includes loss of function to the level of the lowest sacral
segment
Incomplete injury
o Spinal shock
Temporary loss or depression of spinal reflex activity that occurs
below a complete or incomplete spinal cord injury
The lower the spinal cord injury, the more likely that all distal
reflexes will be affected
o Anterior cord syndrome
Loss of motor function, pain and temp sensation distal to the lesion
Results from damage to: corticospinal and/or spinothalamic
pathways, contusion of the cord or bony-injury (flexion of cervical
spine)
Worst prognosis of all injuries
o Central cord syndrome
Decreased motor function, pain and to a lesser exten temperature
sensation, greater in upper than lower extremeties
Due to damage to corticospinal pathway and/or spinothalamic
pathway
Causes: usually in older pts wtith pre-existing cervical spondylosis
wo sustain a hyperextension injury
Thrombosis of anterior spinal artery
o Leads to
Masses
o Brown-Segard syndrome

Patients will exhibit ipsilateral loss of:

o Motor function, proprioception, vibratory sensation
Contralateral loss of pain and temperature sensation
Results from hemisection of the spinal cord
Causes
o Disk protrusions, penetrating trauma (GSW), hematomas
bone injury, tumors
Best prognosis for recovery
o Clinical approach
Always assume a spinal cord injury until proven otherwise
ABCs are top priority but with assumption of cervical spine injury
o Key historical components
Mechanism of injury
Loss of consciousness
Neurologic complaints
o You can use the cremasteric reflex to test for testicular torsion
o Use reflex testing to assess spinal shock (presence, extent,
and/or location)
o Radiographs
Advantages
o Quick and easy
o Rapid turnaround on viewing/interpretation
Disadvantages

o Limited compared to other modalities

o CT scans
Advantages
o More info than radiographs
o More sensitive than plain films
o Great for detecting blood
Disadvantages
o Pt must be stable
o Much more radiation than plain films
o Usually require interpretation by radiologist
o Cannot give any info on spinal cord
o MRI
Advantages
o Gives lots of info about bones, cord, vasculature
o More sensitive than CT scans
o Great for detecting spinal cord injury, ischemia
o No radiation
Disadvantages
o Not good for blood
o Pt must be stable
o Takes a long time

o Requires interpretation by radiologist

o Pts with metal cannot have study
o H&P
GCS, mental exam, intoxicants?
Pt status (stable vs unstable)
Capabilities of facilities (keep vs. transfer)
Get a good mechanism of injury
o 08/21/13
o
o Vestibular system
It is better to have a peripheral nystagmus than a central one
o Peripheral deals with the middle/inner ear and central deals
with the brain
o Menieres disease
Correlates with a high salt diet
Can be autoimmune as well
o Vestibular neuritis
Vs menieres disease
o They cant do anything (non-functional); very debilitating
o Benign paroxysmal positional vertigo
Provoked by head movement (particularly rotation)

r/o orthostatic hypotension by lack of effect of fluid administration

o ALWAYS BE CAREFUL WITH OLDER PATIENTS BECAUSE THEY
OFTEN HAVE ABNORMAL PRESENTATIONS
o 08/26/13 Back Pain
o
o CC: My back hurts
Differential diagnosis
o Herniated disck, cholelithiasis, tumor, kidney stone, thight
psoas, nephritis, AAA or dissection, pulled muscle, vertebral
fracture
How does age affect diagnosis
o Young, old, adult changes most likely causes
PMH/PSH
o Surgeries, previous injuries, repeat problems
Which of the following could be the most concerning symptom (no
correct answer because it could be any of them)
o Blood in urine
Indicates kidney stone, UTI, ant kind of infection
o Pain in the legs
Herniated disk, sciatica
o Numbness
Cauda equina, nerve impingement
Find out if its localized, dermatomal, etc.
o Fever
Any kind of infection, psoas abscess, cholelithiasis,
spinal meningitis, discitis, epidural abcess

o Weakness (paresis)
OLD CARTS
o O: began abruptly while studying in the dorm
o L: left lower back
o D: 2 hrs
o C: sharp and achey
o A: nothing makes it worse or better
o R: radiation to groin
o T: has been constant since onset with waxing and waning
o S: rates it as a 10/10
Differential:
o Kidney stone, musculoskeletal, atypical appendicitis
presentation (retrocecal appendices cause pain on left;
pregnant females commonly have abnormal appendicitis
presentation)
PMH: none
Meds: denies any med use
Allergies: NKDA
SH: student, single, roommat of jeff smith, denies any tobacco or
illicit drug use, social etoh
FH: DM
Sexual Hx: sexually active, one or many partner, male female or
both, do you use protection and if so what kind, have you been
tested, have you or your partner ever been diagnosed with an STI
ROS:
o Hx of dysuria, hematuria, ROM in back, weight change
(cancer), fever, cough and sputum (pneumonia), chest pain
(MI, aortic dissection, AAA), abd pain, discharge (STI)
Pain can be referred if its visceral

Top three diagnoses

o Kidney stones, UTI, STI
Physical exam findings
o Musculoskeletal exam
o Abdominal exam
o GU exam
Could have UTI, STI, testicular torsion, kidney stone
What do you prescribe
o Tordol (NSAID); better for collicy pain
o OMT
o Morphene
o To differentiate between somatic and visceral pain, ask if they
can find a comfortable position to sit or if theyre constantly
uncomfortable
If yes, its likely visceral/peritoneal irritation
You can also do a heel tap
o
o Musculoskeletal injuries tend to have reproducible pain
o
o Testicular torsion tends to be a testicle and the associated vas
deferens twisted around itself
o
o 09/09/13 Mental Status
o

o - 86 y/o confused female

Home Health Nurse said that she had slurred speech, was confused,
and not her normal self
Perform a mini-mental exam, examine skin for bruises/lesions
indicating a fall or infection, a/o to person and place (not time),
does it hurt to urinate, any trouble holding coffee, is there a
number they can reach the home health nurse, she takes insulin
and some pills (doesnt know what they all are) nurse gave her
insulin today,
o Ask paramedics (pt is confused, family and HHN are absent)
for info
HPI
o Hard to get d/t pt being confused
o - Altered Mental Status is the medical terminology for
confusion
Main task in these patients
o Determine if the cause is life-threatening or not
o Determine the cause, in general
o - Hx of alcohol abuse
Empty liquor bottles near the kitchen sink
o Will interact with aspirin
She denies use of alcohol
PMHx
o Diabetic
Blood sugar OK
o HTN
o Hyperlipidemia
o CAD/MI
o Thyroid disease (hypo)

Medications
o Get from slides
Lives in an assisted living
o Lives in assisted living
o Window of Erwin
o Mother of John
o Former smoker
o - Cincinnati test to assess stroke
o - Perform Physical exam
Most cost effective and yields great results
o - CT scan, alcohol level
o - you must determine if this is an organic process or if this is
a functional psychiatric disorder
o - Delirium
An acute state of confusion that often occurs in response to an
identifiable trigger (alcohol in this case)
o - Dementia
A progressive decline in intellectual function that affects social and
occupational functioning

o 9/16/13 Red Eye

o
o - CC: red eye
Is it painful?

o Scleral or corneal abrasion

Does he wear glasses or contacts
Number one infection associated with contacts is pseudomonas
o Where do you work
Day care, welding, animals
o - ROS
headaches, vision changes, photophobia, ataxia, nausea and
vomiting (d/t/ increased intracranial pressure)
o - if it is relieved with topical anesthetics it is likely an injured
surface structure (i.e. cornea)
o - visual acuity is a vital sign for the eye
o - normal intraocular pressure: 10-15, 12-16 (somewhere in
that range)
increased is indicative of glaucoma
o eye will be less reactive (will be dilated and sometimes
somewhat fixed)
o loss of a red reflex
o - hyphema
blood in the anterior chamber (head trauma, pts on blood thinners,
sickle cell causes additional problems)
o - Anisocoria
different sized pupils
o can be physiologic but otherwise is indicative of increased
ICP, pupillary defect
o - chemosis
inflammation, allergic type reaction swelling of the sclera (selflimiting
o anti-histamines for treatment

o - corneal ulcer
fluffy white spot
o - dendritic lesion
from herpes; vision threatening
o 9/17/13 - Eye Case Studies
o
o - Case 1 blurry vision, tired, weak, extreme thirst
eye exam unremarkable
next step?
o Check for DM
There are symptoms other than those that affect the eye, but the
eye component is a part of that systemic effects of this disease
o Blurry vision d/t diabetic retinopathy (usually takes time to
occur)
o dehydration
o The lens in your eye attracts glucose attraction of water
(osmotic pressure/gradient) into lens swollen lens
This will happen whenever the sugar goes high (nondevelopmental)
Acute condition
Pre-diabetes = glucose intolerance
o Plasma glucose between 120 and 200
o
o - Case 2

anemia can cause pale/white appearing conjunctiva

you pt doesnt have to present with an eye complaint to have a
eye-related signs/manifestation of a disease
o
o - Case 3 Biker
foreign body
when motorbikers go at high speed, small particles are heading
towards them very quickly that can go into the eye
have pt stay very still and use 25 gage needle to pick it out
o if pt cant stay still, use a swab
o
o - Case 4
fundoscopic exam indicates optic disc edema
o diabetes doesnt cause optic disc edema/papilledema; also,
no thirst, fatigue, increased urination, vision loss
pseudotumor cerebri
o increased CSF pressure (d/t obstruction of flow or
overproduction) optic disc edema
will present with non-specific headaches, nausea,
vomiting
CT head, if negative then do spinal tap
o Could have viral/aseptic meningitis causing increased ICP
o Spinal taps will also tell you the pressure of CSF as well as
allow you to drain some CSF
Spinal taps often cause headaches (spinal headaches);
can also cause infections, diskitis, etc.
o
o - Case 5

hyperthyroidism
exophthalmos present
o you can see the top of their iris
o
o - Case 6
CT of head without contrast
o Dont give with contrast, because the contrast can be
confused with a bleed
Anisocoria
o Can be normal
o Can be due to increased intracranial pressure herniation
o
o - Case 7 Jail fight
Do a CT of the head to r/o skull fracture
o Raccoon eyes are present (indicate skull fracture)

- Case 8
Intracranial injury with possible orbital fracture, brain herniation
o
o - Case 9
spontaneous subconjunctival hemorrhage (often d/t
thrombocytopenia)
o trauma can cause it

o not hyphemia because theres no blood in the cornea

o
o 09/23/13 Sorethroat Cases
o
o - basics
history, history, history
detailed physical exam
appearance
o are they eating, drinking, happy; or do they look miserable
know your anatomy well
risk stratification
create a detailed differential list (most likely to least likely)
diagnostic tests, if necessary, that can help in your diagnosis
appropriate tx
many parents come to office just for antibiotics
o when antibiotics are contraindicated, you must educate them
as to why
o - basics of oral examination
look for redness; area between tonsils and uvula, uvula and
toungue; pus; symmetry
look at hard and soft palate for lesions and symmetry
o uvula can naturally deviate to one side, so ask pt if it is
normal for them
o - Case 1

diff dx:
o viral pharyngitis (adenovirus), mononucleosis, rhinovirus,
coronavirus, Influenza virus
o - Case 2
red mucosa, pus from tonsils, swelling closure of throat, uvula in
midline but with less space between it and tonsils
exudative tonsillitis
o if exudate was coming from post aspect of oral area
(pharynx) it would by exudative pharyngitis
by the book
o adenovirus will present with rhinitis symptoms and strep
pyogenes will present with abdominal pain, nausea and
diarrhea, but in real life pts often present with mixed
symptoms (often due to multiple infections)
o - Case 3
diff dx
o mono, immunocompromised, viral syndrome (flu), incorrect
antibiotic prescribed, pt didnt take antibiotic or took it
incorrectly, antibiotic resistant agent, acute retroviral
syndrome, oral STI, bacteremia
if multiple treatment attempts dont work, take a step back and rework your differential diagnosis
no sports/physical activity until symptoms resolve because of
splenomegaly
o - mono diagnosis
monospot test
o once youve had mono you will test positive on a monospot
test for up to a year (EBV titers), because youve already
developed titers
lymphocyte infiltration as opposed to PMN and/or macrophage (for
bacteria or viruses)
o - Case 4
differential dx
o mumps, pharyngitis, tonsillitis, viral infection, peritonsillar
abscess (most likely bacterial, so give antibiotics)
physical findings

o erythema, inflammation on left side uvula deviated to the

right d/t swelling (tonsillar infection in peritonsillar space
cellulitis abscess)
o - basics
symmetry
uvula in midline
sig signs on one side vs other (or both)
watch out for carotid artery if draining a peritonsilar abscess

- inflammation without pus is cellulitis, but prolonged cellulitis abscesses;

do a CT to determine which it is
- cut off/re-cap needle so it can only go in a small amount
o
o - Case 5
diff dx
o meningitis, GI flora, bacteremia, pharyngitis,
retropharyngeal abscess (you dont always see during
physical exam)
confirm via CT
look for tracheal deviation
o
o - your eyes, physical exam, and imaging must confirm the
diagnosis
o
o 09/30/13 Increased Thirst
o
o - increased thirst (polydipsia)

textbook definition: thirst unrelieved by drinking fluids

drinking more water than normal with a more difficult time
quenching ones thirst satiety
youre dehydrated
can signify an underlying disease
result of strenuous activity
dry mouth
o
o - Case 1
40 y/o female presents with severe thirst; family members state
that she cant stop drinking
when did it start, how long has it been going on, how much is she
drinking at a time, what are they drinking, what is the urine output
like (urinating constantly or not at all), color of urine and is there
any smell, relieving or aggravating factors, abrupt or gradual onset,
any edema or swelling (do your shoes and rings feel tight or loose,
weight gain >5 lbs/week), current medications (type, dose, and
freq.), allergies, diarrhea, fatigue, dietary changes (salt intake),
blurry vision, fever (brain infection can cause change in set points,
blood loss, replacing dead cells requires fluids, could affect kidneys,
fevers cause sweating), polyphagia (increased hunger), menstrual
cycle (blood loss - menorrhagia), excess facial hair hiursutism or
excess lactation (endocrine/pituitary dysfunction), hair loss
alopecia, head trauma, GI blood loss, diabetes, liver (cirrhosis
inflammation/degradation of hepatic cells; d/t hepatitis, chronic
alcoholism, etc. electrolyte imbalances thirst)
physical exam
o dry lips, ulcerative/scabbed (means it has been going on)
o
- anticholinergic toxicity (IN POWERPOINT)

o - edema
o
o - skin turgor
skin retraction test: pinch the skin on the dorsum of your hand and
observe for tenting
o
o - mental status is very important in evaluating a patient with
increased thirst

pts with hyper- or hyponatremia will have mental status changes,

drug toxicity, could be hyperglycemic, psychogenic polydipsia
o
o - main Qs
polyuria, polyphagia, weight gain, recent water loss, Hx of acute
blood loss, etc.
o
o - main causes of polydipsia
uncontrolled diabetes mellitus, diabeted insipidous (can be central
d/t vasopressin/ADH depression or nephrogenic kidneys fail to
recognize vasopressin/ADH), psychogenic polydipsia, anticholinergic
toxicity
o to distinguish between DM and DI, do urine analysis
(electrolytes - K+ and Na+ in particular, low osmolality in DI)
o
o 10/7/2013 Endocrine
o
o - Larry Brown
O: 6 months
L: calves (L more than R)
D: 7-9 minutes
C: Tightness (like a charlie horse)
A: running makes it worse
A: urinates more freq since starting BP meds (hydrochlorothiazide 4
yrs ago)
R: stretching and rubbing the back of the calf
T: worse at night
S: 4/10 (feeling more sore at the moment)

Diet: regular diet

o - Spinach has much more potassium than bananas
o - Differential
Dehydration, electrolyte imbalance, DVT
o - PMHx
HTN,
o - medication
HCTZ, aleve
o - NKA
o - lives with wife and son; smokes pack of cigarettes a day
and occasional beer; auto mechanic
o - what is a crampy, deep pain in an extremity after exercise
caused by HCTZ and relieved with rest called
claudication
o - Next step
get a D-dimer to check for DVT (if a woman is present she will
always be D-dimer positive)
BMB, urinalysis
o - step needed to confirm diagnosis
o - most urgent next step
EKG
o Will detect hyper- and hypokalemia
o - % body water in a 40-60 yr old is 55%
o - you can diagnose rhabdomyolysis if you find myoglobin in
the urine

o - excessive amounts of running can cause compartment

syndrome
myelin breakdown, edema, rhabdo,
o - hypercalcemia does not cause leg cramps
(hypomagnesemia, hypokalemia, and hyperphosphatemia do)
o - people on HCTZ lose Ca2+
o - read article posted on blackboard
o - quiz on Thursday (hypokalemia and hyperkalemia)
know clinical findings and treatments
o 10/21/13 Joint Pain
o
o - 44 y/o male presents to the PMDs office with knee pain
OLD CAARRTS, one or both knees, what part of the knee, does it
always hurt or does it come and go, what makes it worse (maybe
give him suggestions like when going upstairs or downstairs or
running), if nothing makes it better include the questions you
asked/possible things that they tried to help it (i.e. meds, ice, rest),
MOI (mechanism of injury), associated sound/pop, any rash
associated, previous injuries or surgeries, recent infection/illness
(i.e. diarrhea), if pt is older (74) cancer is a possibility (colon, lung
and prostate are most common, hip pain gait
compensation/abnormality dysfunctional knees, falls,
osteoporosis,), if pt is younger (playing sports, growing pains,
Osgood schauders/tibial epophysitis)
o - location
Unilateral (trauma) vs bilateral (systemic response)
Anterior (Osgood schlauters, patellar tendonitis and dislocation) vs.
medial (MCL, medial meniscus) vs. lateral (LCL, fibular head, IT
band) vs. posterior (
DVT, bakers cyst)
o - McMurray is the test for torn meniscus
o - neer and hawkins are for rotator cuff injuries
o - pes anserine
Sartorius aids in knee and hip flexion, as in sitting or climing;
abducts and laterally rotates thigh

It means goose foot

o - trauma to knee
ACL, PCL, LCL, MCL, meniscus injury, patella dislocation, fracture,
sprain, subluxation
Do a thorough history so that you dont always have to do an X-ray
o - infection
strep throat, septic joint, lyme, cellulitis, osteomyelitis
o - inflammatory
arthritis, bursitis, hemophilias, rheumatoid arthritis, sickle cell,
lupus, gout (vs pseudogouts)
o - Referred
SCFE (slipped capital femoral epiphysis)
o The ice cream is sliding off the cone (anatomical L on Xray
slide)
o Very common in fat adolescent boys
o - Vascular
DVT
o - X-ray of knee
joint space is wider on lateral side (tibial plateau fracture)
o -X-ray of two knees
R knee has osteoarthritis
o - X-ray of knee
man comes in after shoveling knee pain
patella is normal (it is usually above the knee joint space)

osteoarthritis on tibial plateau (normal in older people) visible as

increased opacity
pt has fluid in his thigh (bursa is inflamed or there is inflammatory
fluid leaking out of the joint space)
o physical exam will reveal a very inflamed knee
what pain med would you give
o morphine sulfate (will allow you to manipulate the joint to
take an x-ray or provide treatment)
o - When draining a knee dont walk the syringe along the
posterior border of the patella bone
if you need to use multiple syringes, you can leave the needle in the
knee while changing out syringes (fluid will be milky/non-clear if
fluid is not normal (will be clear if normal)
insert syringe at upper 1/3 mark of patella
give superficial and deep anaesthetic
send fluid for culture (tests for organisms); microbio
look for WBCs (cytology) indicates infection
look for gout crystals (chemistry section)
pseudogout: sodium pyrophosphate?
gout: sodium ureate?
o - when is it appropriate to give a steroid injection in the knee
when there is just an inflammatory reaction in the knee (no
infection, etc.)
o 10/23/13 Rheumatology
o
o Dr. Weiner
o rheumforimprovement@yahoo.com

o
o disease modifying drugs in rheumatoid arthritis
SLE
autoantibodies
Rheumatoid arthritis
Differential dx of acute inflammatory oligoarthrisis
Osteoarthritis
o
o - muscles, joints, and rheumatic diseases (100+ diseases)
o - requires a good Hx because tests exist with very high
sensitivity (i.e. MRI) so if you dont know what youre looking
for youre going to be lost
o - Diarthrodial joints
two bones with cartilage, surrounded by a capsule that is filled with
synovial fluid
most pathology occurs at the articular surface, which is covered
with articular cartilage (lubricates, pads/softens blow/absorbs
shock)
o - Initial characterization of arthritis
acute or chronic
number of joints involved: monoarticular, oligoarticular (2-4), or
polyarticular (5+)
symmetric or asymmetric; additive or migratory (hurts in one joint
for a couple of hours then moves to another joint)
accurate delineation of joints involved
inflammatory (swollen, red, painful joint) or non-inflammatory
is it d/t an infection
just because a certain area hurts doesnt mean that there is a
dysfunction in that area; so Hx is important
i.e. shoulder pain could be d/t spinal nerve impingement, synovitis,
bursitis, etc.
i.e. hip pain/dysfunction can originate in posterior, groin, or knee
- acute onset of one joint (monoarticular arthritis), think
inflammatory
multiple joints, chronic onset, think of something like a tick bite
lyme disease
spondyloarthropathies

o - Differential diagnosis of chronic noninflammatory

monoarthritis
osteoarthritis
o everyone will develop this at some time (generally after 50)
internal derangements
o refer to tendons and cartilage
i.e. torn meniscus
osteonecrosis
o the bone dies
o d/t trauma, steroid use
neuropathic (charcot) arthropathy
o causes pain in the joints
o - common cause of acute monoarthritis
must always be concerned about a septic arthritis (i.e. staph, strep,
gonococcal, gram neg., etc. make enzymes that degrade cartilage)
severely painful joint, they have a fever, may be an inciting event,
immunocompromised individuals
o people with rheumatoid arthritis have a high risk of
developing a septic joint
gout (crystal-induced arthritis)
o increasing in incidence d/t hyperuricemia crystallization in
joints phagocytosis by macrophages release of chemical
mediators inflammation/crystal arthropathy
secondary to poor diet
o gout (monosodium urate crystals) vs pseudogout (calcium
pyrophosphate dehydrate crystals)
o more common in men (30-40), incidence in women increases
after menopause
hemearthrosis d/t trauma

o d/t anticoagulants
o - Differential diagnosiss of chronic inflammatory monoarthritis
Lymes disease
o Common in Lyme, CT; MN; WI
o - Differential diagnosis of acute polyarthritis
SLE
o especially in young women
o skin rash, photosensitivity, reynauds phenomenon
acute viral infections
o Hepatitis C (can positive rheumatoid factor)
o Parvovirus (children have rashes, adults dont; joint pain;
looks like a hand slapped your face type or rash)
Paraneoplastic polyarthritis (away from the malignancy the body
has a rxn to the cancer cells, i.e. SIADH d/t small cell lung cancer)
Sarcoidosis
o Acute presentation, Locran? syndrome; erythema nodosum
(inflammation of fatty tissue deep in sub-Q, pretibial, red
lesion on legs) and hilar adenopathy
Still disease (adult onset)
o Juvenile rheumatoid arthritis for adults
o Presents as a fever of unknown origin (going on for 5+
weeks); many possible causes
Temp spikes one time per day, joint pain, salmon
colored rash
All other tests are neg. (i.e. Ig, etc.)
o Macrophage activation syndrome is a sequelae that has high
mortality
Systemic autoimmune diseases and vasculitides

o Vascular problems that joint pain

o - Differential of oligoarthritis
bacterial endocarditis
o fever, multiple aches and pains, heart murmur
ankylosing spondylitis
o HLA-B27
Psoriatic arthritis
o The skin disease (psoriasis) can hide (behind ears, in anal
cleft, etc.)
o Asymmetric, causes sausage-shaped inflamed joint
Inflammatory bowel disease
o Usually a knee of ankle
o Similar for ulcerative colitis or crohns disease (joints are
often innocent bystanders/sequelae of other diseases)
o - Palpable purpura is indicative of vascular disease
o - Joint issues have many causes to them and can manifest in
many different areas of the body
o - fever and arthritis
reactive arthritis in many dysentery causing bugs
o - hydralazine, propanaline can cause a state that looks like
lupus
o - synovial fluid
has nutrients
should be clear
synovial fluid clarity is determined by the number of WBCs (will
cause the fluid to be turbid)

o - Synovial Fluid Clarity

Class I: Rheumatoid arthritis
Class II: inflammatory (mild)
Class III: infected/septic (severe; purulence)
Hemorrhagic: pt may be on too much blood thinner
o GO TO SLIDES (STARTS AT 21)
o
o 12/9/13
o
o - if you ever have a pt that is diaphoretic, it is not good; you
cant fake it
even worse if theyre cool, pale, and diaphoretic (it means theyre in
shock)
o - CPR and defibrillating when heart isnt beating
o o
o Medical Ethics in Islam
o - if someone has no function other than being able to breathe
on their own, they are not considered dead
o - if the person isnt breathing on their own and if there are no
signs of life, then it is okay to stop life support (life support;
even if the heart is beating)
o - if someone has a terminal condition and a new, lifethreatening condition arises, it is okay to refuse treatment
because they will eventually die anyways and it would just be
postponing the inevitable
o - Against abortion (unless the mothers life is in danger, if the
child is a product of rape or incest first ? days - or if child
has a condition that is incompatible w/ life must be in first
120 days)
o - contraception is okay, so long as it isnt permanent (i.e.
tubal ligation, etc.) unless the persons life is in danger
o - artificial insemination is only permitted if it preserves the
lineage of the marriage (no sperm or egg donors, but in vitro
fertilization is okay)

surrogate mothers discouraged

o - adoption is highly encouraged for couples who are unable to
have children (the child is supposed to keep their last name to
preserve their lineage)
maintenance of lineage is very important marriage is meant to
preserve lineages
o - elective plastic surgery is NOT allowed, but if it is medically
necessary or as a result of some trauma (burn, etc.) then it is
allowed
o
o Medical Ethics in Judaism
o - agrees with Islam with most all subjects
o - we see ourselves as being made in the image of God and
are supposed to live trying to live as he would
you shall be holy for I, the lord am holy
o - choose life (the gift and the curse, life and death
Deuteronomy)
the preservation of life is the most important commandment (3
exceptions)
o murder (you should die rather than do it)
o incest and adultery (you deserve to die)
o an example of idolatry to the community
o - to save a life is to save the whole world
o - Life support
if the person is dead before you put them on life support, then
removing it is not killing them, because they were already dead
prior to its application
o - End of life
old definitions/requirements
o cessation of heart beat (visual or audial)
o cessation of breathing

o there was no permission for organ transplantation from a

brain dead individual
New definitions
o If someone is brain dead, there is no spontaneous heart beat,
so they are considered dead and can donate organs
o People are supposed to be buried whole, but since the organ
transplants save lives, they are permitted
o - DNRs
name has been changed to no emergency CPR
o preserves the patient name so theyre not referred to as DNR
we keep the pt alive as long as possible, until the medical
professionals determine that there is no real life and that the
person can not be resuscitated (2 examples)
o Sve Merat: someone who is dying slowly in the hospital
o Someone who is going to die in the next hour
o - body should be buried whole in the earth
autopsys used to be prohibited because it involves mutilating the
body, but the stance has changed because the knowledge that can
be attained from performing the autopsy can save lives (you cant
do an autopsy if its exploratory)
o - Continuity of life is paramount
o - contraception and abortion
similar to Islam
o if mothers life is in danger
Preservation of life is paramount
o - plastic surgery
not a problem
o - saving life takes precedence over everything (including
Sabbath, restrictions of food/kosher, etc.)
o - everything that you do should have a medical goal, so if
there is no beneficial outcome to your treatment, you
shouldnt do it

o
o Christian (Protestant)
o - Body, mind, and soul are good (there is no one precedent
over the other)
you always try to affirm all three aspects; however, in medicine,
there is often a give and take between these three
o - I am more than my body, but my body is part of the more
that is me
quote of paraplegic woman who refused to be a poster-girl for stem
cell research, because she felt it would reduce her to her body
o - Glyduride
pancreatic stimulant that can cause hypoglycemia
shouldnt diminish quality of life, even in diabeticsyou just have to
monitor it a little
o - Prozac
returns brain chemistry to normal, but takes away from a pts ability
to express themselves (saves the body but diminishes from the
soul)
o - They believe that they should love God with all of your
mind, body and soul (the affirmation of the three main
qualities)
loving yourself, others, and God are encompassed in any one act of
love
make sure your medical decision maximizes their love
o have a conversation between the practitioner, pt, family,
pasture, and God to choose a course of treatment that will
maximize this trio of qualities
o - you must determine if life after death is better than what life
currently is when trying to come to a decision on treatment
o - They believe that God can heal and some people want to do
everything that they can to make a person well; but, you
must confront the reality that death will come
help them deal with pressing and important issues
o - a reasonable chance of success of a treatment must exist
when determining a course of action in end of life care
success must be defined from the perspectives of the physical, pt,
and family
you should give them all information so that they can make a
decision as to what will be best for their whole body

o
o Roman Catholicism
o - hierarchical organization
o - the Holy father pope is infallible only in matters of faith and
morals
o - life begins at conception and must be protected and
respected absolutely from that moment onwards
against procured abortions of all kinds
o church does not judge or condemn the mother or abortionist,
but reaches out to extend their gods mercy towards them
stem cell research is prohibited (because it destroys the embryo)
adult stem cell and umbilical blood use is okay
o - Euthanasia
morally unacceptable
those whose lives are diminished or weakened should be respected
and helped
EXCEPTION
o If medical intervention is futile, it is okay not to proceed with
further treatment
This does NOT include hydration and nutrition, which
may NEVER be withheld in order to hasten death
o - organ donation
okay after death
okay for a living person so long as it doesnt mutilate the body (i.e.
eyes)
o - Afterlife
those who die in Gods grace, but imperfectly purified go to
purgatory
o - the church condemns nobody, because only their god knows
the state of their soul at death

the church provides a sacrament at death to assist in the passing

over into eternal life
o - the church tends not to make medical decisions, it will make
its stance on certain medical conditions and treatments
known, however
o
o
o - when asked if treatments are futile by a dying pts family,
the physician should never say its up to you. It is up to the
physician to educate them and help them to make a decision
based on the medical state of the individual
o
o
o
o
o Odynophagia painful swallowing
o
o Motility both solids and liquids
o variable presentation
o -acutely
o -chronic
o -after stroke
o -achalasia common on boards
o
o In clinical practice rarely jump straight to barioum swallow. Pt
having motility issues catn swallow!
o Boards -> barium swallow
o

o
o
o
o
o
o
o
o
o
o

Odynophagia KNOW, esp infectious causes!!! Test ?

Endoscopy will not help diagnose a motility problem, duh

pH helps to confirm non-GERD diagnosis

GERD:
***Lifestyle changes are first line Tx. Least cost and most
effective
o KNOW specific lifestyle changes that have been proven
effective aka those on slide
o
o Clinical Dx:
o Teat w PPI, if they get better, they have GERD
o
o Proceed to GI doc if PPI s fail or pt has alarm Sx wt loss, FE
def anemia
o pH testing useful to confirm NON-gerd Dx
o
o Functional disorder=IBS
o
o PPI keeps Barretts from progressing further

o
o
o
o
o
o
o

***BARRETTS Esophagus -slide

HALO = radiofrequency ablation

GERD Tx
Know PPI side effects bc we are responsible for adverse
effects on pts
o These lifestyle mods less successful
o LINX: magnets act as LES
o
o Infectious Esophagitis
o HSV: often in immunocompromised but can affect healthy
people
o
o IMAGES:
o Top left candida biopsy top layer
o Bottom left: CMV biopsy center - starts with C organism in
Center
o Bottom right: HSV biopsy margin of uulcer
o
o (Alendrolatre for osteoporosis)
o
o Caustic Injury is a risk factor for squamous carcinoma which
rare in esophagous

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

Mallory Weiss tears: alcoholics, bulimia

**Eosiniphilic Esophagitis
Young pt long hx allx asthma
Progressive dysphagia, food impaction
Furrowing
Histologoic Dx > 15 eosinophils
Must tx underlying issue: Flucacortisone, PPIs
Rings = corrugated
Furrowing = lines/grooves
Plummer vinson: common on boards
Zenkers: at Killians triangle(upper esophagus)
Old undigested food in throat, may wake up with food on
pillow etc

o
o Neoplasms:
o Most common Leiomyoma
o

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

E ultrasound to dx
Esophageal varices
-usually with portal htn
-cirrhosis
rupture->bleeding presents emergency
If you dx cirrhosis check for eso varices
Achalasia motility BOARDS
Will try to confuse us on boards not hyperactive LES
Look for aperistalsis, and LES FAILS TO RELAX
Older ppl with gradual onset progresvive dysphagia
BIRDS BEAK on esophagram
Bottom right: huge dilated esophagus
Commonly: Idiopathic, Chagas,
ANNA-1 may be on boards
Poor surgical candidates = commonly elderly

o
o Heller myotomy The esophagus is made of several layers,
and the myotomy only cuts through the outside muscle layers
which are squeezing it shut, leaving the inner mucosal layer
intact.
o
o Bonus questions: will not be on test
o Upper(white) from FA 2013
o Obestity or GERD do not lead to cancer but obesity -> GERD
-> Barretts -> carcinoma
o
o Achalasia is a risk factor for squamous CA
o
o Bottom othercauses sq CA esophagus
o - Caustic causes swalling lye
o
o Alcohol direct toxin, drinking causes gastritis
o EXTERNAL Burn injuries very severe (curling ulcers)
o
o Sever abdominal pain usually not gastritis
o Gastritis by itself often doesn't cause bledding. Need ulcers,
tear etc
o
o (Sulcrafate = agent used during codes)
o
o Best way to prevent gastritis = EAT, food absorbs
acid/irritants

o
o PPI gtt = PPI drip, usually in hospital setting
o
o Portal HTN gastropathy
Chronic GI bleeding
Watermelon stomach
GAVE image= red lines = bleeding, looks like watermelon
***H pylori know slides
Must treat if Dx bc it leads to gastric adenoma, MALToma
Breath test in clinical practice more frequently used to confirm eradication
Stool Ab about 90% sensitive
Serology not helpful for dx
Histology = gold standard for dx
Pernicious anemia + B12 def could be caused by carcinoma
B12 def in healthy person should always raise suspicion
-takes years to deplete liver stores

Menetrier Ds BOARDS
Anasarca edema all over body often from protein deficiency
Biopsy margin of ulcers >2cm
Gastric
***PUD (particularly slide before PUD causes?)
Gatrinoma: Old pt, chronic diarrhea, PUD
Cimetidine: inhibits P450, many interactions warfarin, coumadin
Unusual Ulcers:
Camerons: as stomach gets pulled back and forth in LES it rubs diaphragm
ZE: multiple duodenal ulcers
Duodenal ulcers: common unusual cause celiac

Complications (may be test question)

Reccurent ulcers -> inflammation->obstruction
-pylorus is normally only 5mm, esily blocked with excessive inflame
ZE:

Gastinoma:
o older, wt loss, chronic diarrhea -> do a secretin test (rise in
gastrin >200 suggests ZE)
image: diffuse ulcers throughout duodenum
glucagonoma(in pancreas) may present with low glucose
o
o Other causes high gastrin level
Obstruction
Vagotomy vagus nerve cut during stomach surgx
renal failure gastrin no longer cleared at normal rate
o
o
o ***Benign Neoplasm of stomach - SLIDE

o chronic PPI use

o
o Gastric CA
o Intestinal
H pylori
Smoked food, menetrier, atrophic gastritis
o Diffuse:
Much worse
Signet rings on biopsy
Linnitus plstica thick leathery
o
o
o
o
o
o
o

Testable stops at Gastric CA image

IBS All tests come back normal
Often presents when under stress

Bonus questions
Lab abnormality upper gi bleed: on CMB -> high BUN, with
normal creatinine
Blood makes nitrogen, normal kidney function
o
o Abd pain, normal lipse(marker for pancreatitis), elevated
amylase: duodenal ulcer could be aggravating pancreas
o
o Gastric mass w spindle cells?: GIST, gastrointestinal tumor
o
o Inhibition other than H2 blocker or PPI? acetylcholine
o
o
o
o